October 20, 2012

India: Uttar Pradesh, Bihar struggle to combat Japanese encephalitis

GORAKHPUR: The Rs 4,000 crore [US$256 million] package cleared by the union cabinet to fight encephalitis on Thursday will not come a moment too soon for thousands of families across eastern UP and Bihar. Over 440 children have died in Gorakhpur division alone just this year, adding to the region's 35-year struggle with the disease that has taken the lives of an estimated 50,000 children.

In eastern UP, better known as Poorvanchal, a perfect storm has gathered. High population density combined with high rates of poverty, chronic malnourishment and low levels of education collide with unfavourable topography, poor drinking water provision and sanitation to create ideal conditions for the spread of encephalitis at a magnitude that all but overwhelms the region's sole major hospital, BRD Medical College in Gorakhpur city.

The region is low-lying and surrounded by rivers, leaving it in the unusual position of having a dangerously high groundwater level. "In most of the country, falling groundwater levels is a serious problem, but in this region, the problem is that the water table is very high, making contamination, especially after the rains, much easier," said Gorakhpur district magistrate Ravi Kumar NG.

Cheaper shallow handpumps give rural residents easier access to water, but are far more susceptible to contamination than more expensive, deeper ones. In addition, piggeries located within human habitations are common in the region, their relocation a vexed issue the administration has been trying to grapple with.

"Most of the children who come here are quite malnourished and come from poor families," said Dr Bharti Bhandari, one of the dozens of young doctors on 18-hour shifts - with no holidays - at work at BRD Medical College. Two and three children crowded each bed, even in the ICUs, their parents sleeping on the floor near them.

Jagat Singh, an agricultural labourer, tried to comfort his three-and-a-half year-old grandson, Krish Kumar. The family had come from Gopalganj in Bihar after the boy started convulsing. In the ICU, Murshid Alam, a driver, kept a close watch on his 16 month-old son, Wasim, who was on the ventilator. He had come from Paschimi Champaran in Bihar.

The hospital caters to over ten districts of Uttar Pradesh as well as to patients from Bihar, Jharkhand and Nepal, registering staggering numbers. Over 2,500 new patients visit its OPD every day, and at any given point, it has 90-100 new born children in its neo-natal unit. Come July, the already overburdened hospital is simply inundated with paediatric encephalitis cases - close to 3,000 this year alone, in a hospital with 222 beds for paediatric cases.

The greatest challenge it faces, though, is an acute shortage of medical and para-medical staff.

"We face an acute shortage of specialists and have to draft in doctors from other hospitals and research students for these months every year," said Dr K P Kushwaha, principal of BRD Medical College. "Our PG students are seeing 300 patients where they should be seeing 30 and are left with little time to study," he added.

For the last five years, doctors and researchers have been observing a fall in the proportion of mosquito-borne Japanese Encephalitis (JE) cases in the total number, and a rise in the number of water-borne Acute Encephalitis Syndrome (AES) cases.

"In 2006, the proportion of JE cases in the total was found to be 28 per cent, after which there were mass immunisation drives in 2006 and 2010. The proportion of JE has now fallen to around 5.5 per cent," said Dr Kushwaha.

"AES can be caused by a whole range of enteric viruses," said Dr Milind Gore who heads the National Institute of Virology's Gorakhpur research mission. "We have isolated some of these, but at least for now, no vaccine exists for them, and prevention as well as management of the symptoms is the only course of action," said Dr Gore.

Comments

GORAKHPUR: The Rs 4,000 crore [US$256 million] package cleared by the union cabinet to fight encephalitis on Thursday will not come a moment too soon for thousands of families across eastern UP and Bihar. Over 440 children have died in Gorakhpur division alone just this year, adding to the region's 35-year struggle with the disease that has taken the lives of an estimated 50,000 children.

In eastern UP, better known as Poorvanchal, a perfect storm has gathered. High population density combined with high rates of poverty, chronic malnourishment and low levels of education collide with unfavourable topography, poor drinking water provision and sanitation to create ideal conditions for the spread of encephalitis at a magnitude that all but overwhelms the region's sole major hospital, BRD Medical College in Gorakhpur city.

The region is low-lying and surrounded by rivers, leaving it in the unusual position of having a dangerously high groundwater level. "In most of the country, falling groundwater levels is a serious problem, but in this region, the problem is that the water table is very high, making contamination, especially after the rains, much easier," said Gorakhpur district magistrate Ravi Kumar NG.

Cheaper shallow handpumps give rural residents easier access to water, but are far more susceptible to contamination than more expensive, deeper ones. In addition, piggeries located within human habitations are common in the region, their relocation a vexed issue the administration has been trying to grapple with.

"Most of the children who come here are quite malnourished and come from poor families," said Dr Bharti Bhandari, one of the dozens of young doctors on 18-hour shifts - with no holidays - at work at BRD Medical College. Two and three children crowded each bed, even in the ICUs, their parents sleeping on the floor near them.

Jagat Singh, an agricultural labourer, tried to comfort his three-and-a-half year-old grandson, Krish Kumar. The family had come from Gopalganj in Bihar after the boy started convulsing. In the ICU, Murshid Alam, a driver, kept a close watch on his 16 month-old son, Wasim, who was on the ventilator. He had come from Paschimi Champaran in Bihar.

The hospital caters to over ten districts of Uttar Pradesh as well as to patients from Bihar, Jharkhand and Nepal, registering staggering numbers. Over 2,500 new patients visit its OPD every day, and at any given point, it has 90-100 new born children in its neo-natal unit. Come July, the already overburdened hospital is simply inundated with paediatric encephalitis cases - close to 3,000 this year alone, in a hospital with 222 beds for paediatric cases.

The greatest challenge it faces, though, is an acute shortage of medical and para-medical staff.

"We face an acute shortage of specialists and have to draft in doctors from other hospitals and research students for these months every year," said Dr K P Kushwaha, principal of BRD Medical College. "Our PG students are seeing 300 patients where they should be seeing 30 and are left with little time to study," he added.

For the last five years, doctors and researchers have been observing a fall in the proportion of mosquito-borne Japanese Encephalitis (JE) cases in the total number, and a rise in the number of water-borne Acute Encephalitis Syndrome (AES) cases.

"In 2006, the proportion of JE cases in the total was found to be 28 per cent, after which there were mass immunisation drives in 2006 and 2010. The proportion of JE has now fallen to around 5.5 per cent," said Dr Kushwaha.

"AES can be caused by a whole range of enteric viruses," said Dr Milind Gore who heads the National Institute of Virology's Gorakhpur research mission. "We have isolated some of these, but at least for now, no vaccine exists for them, and prevention as well as management of the symptoms is the only course of action," said Dr Gore.